Innovation and Professional Realignments

Doctor and — back to the apothecary!

Siaw-Teng Liaw and Gregory Peterson

Abstract THE AUSTRALIAN health care environment faces a The Australian National Policy embod- number of challenges related to the increase in ies four tenets: availability, quality, safety and chronic illness, an ageing society, feminisation of efficacy of medicines; timely access to affordable medicines; quality use of medicines (QUM); and a the health workforce, increasing specialisation, responsible and viable medicines industry. The escalating costs of health care, rising patient promotion of QUM requires a multidisciplinary expectations, the worried well, and the attenua- approach, including contributions from govern- tion of the traditional relationship between ment, the pharmaceutical industry, health profes- increasingly mobile working families and their sionals, consumers and academia. However, family doctors. Australian health care is tradition- there areAust significantHealth Rev ISSN:tensions 0156-5788 and unintended1 May ally episodic, based on separate encounters with a effects 2009associated 33 2 268-278 with the multidisciplinary number of independent providers. This frag- ©Aust Health Rev 2009 www.ausheal- approach, especially with the relationships mented care, along with poor communication betweenthreview.com.au prescribers and dispensers of medicines. Innovation and Professional and inconsistencies in health practice within a The generalRealignments practitioner and the pharmacist share complex environment and knowledge base, also a common ancestor — the apothecary. The sepa- makes it difficult for the patient to understand ration of dispensing from prescribing, which and manage their illness and care. began in medieval Europe and 19th century Eng- The Chronic Care Model in the United States1 land, reframed and confined the patient–doctor and the Expert Patient Program in the United relationship to one of diagnosis, prescription and 2 non-drug management. The role of Kingdom place the partnership between the was limited to dispensing, though the present patient and clinician/practice as a central compo- trend is for their responsibilities to be widened. nent of successful care of chronic illness. The Historical antecedents, the contribution of an vision is one of “activated” and engaged patients increasing number of actors to the costs of health in full control of the management of their own care, universal health insurance and an evolving illness. This underpins the importance of patient- regulatory framework, are among the factors influ- centred care and highlights the centrality of the encing doctor–pharmacist relations. clinician–patient therapeutic relationship. The prescribing and dispensing of medicines must This paper focuses on the relationship between be guided by an ethical clinical governance struc- two key players in the quality use of medicines: ture encompassing health professionals, regula- the general practitioner and the pharmacist. The tors, the pharmaceutical industry and consumers. There must be close monitoring of safety and effectiveness, and promotion of quality use of Siaw-Teng Liaw, PhD, FRACGP, FACHI, Professor of medicines and improved patient outcomes. Ongo- General Practice, University of New South Wales; and ing training and professional development, within Director and across professional boundaries, is essential General Practice Unit, Fairfield Hospital, Sydney South West to support harmonious and cost-effective inter- Area Health Service, Sydney, NSW. professional practice. The approach must be Gregory M Peterson, PhD, MBA, FSHP, FACP, AACPA, “apothecarial” with complementary roles and Professor of and Head School of Pharmacy, University of Tasmania, Hobart, TAS. responsibilities for the prescriber and dispenser within the patient–clinician therapeutic relation- Correspondence: Professor Siaw-Teng Liaw, General Practice Unit, Fairfield Hospital, Sydney South West Area Health ship, and not adversarial. Service, PO Box 5, Fairfield, Sydney, NSW 1860. Aust Health Rev 2009: 33(2): 268–278 [email protected]

268 Australian Health Review May 2009 Vol 33 No 2 Innovation and Professional Realignments general practitioner and the pharmacist share a fits Scheme (PBS) and Medicare Benefits Scheme common ancestor — the apothecary — who (MBS). In addition, there is a cap on individual or diagnosed, prescribed and dispensed a . household annual out-of-pocket expenditure on The apothecary’s medicine embodied medical medicines and health services after which subsi- knowledge and underpinned the patient’s expec- dies for PBS and MBS services are extended tation of a medicine as the “product” of patient– further or made available for free. The Repatria- doctor interaction.3 The skill of the diagnostician tion PBS (RPBS) provides veterans with subsi- was embedded in the prescription, and payment dised medicines. Medicines included in the PBS was for the medicine, the tangible output of the may be prescribed in three categories: (1) unre- encounter. With dispensing separated from diag- stricted, (2) restricted to specific conditions, or nosis and prescribing, the doctor’s direct link to (3) requiring an authority to prescribe. An the symbolic value of the prescribed medicine is authority to prescribe entails a telephone call with diminished. The doctor is also no longer a pur- a trained clerical person — a cost containment veyor of medicines. approach resented by many doctors.4 The The doctor–pharmacist relationship will also be recently introduced streamlined authority codes examined in the context of an increasingly com- scheme5 allows doctors to prescribe a list of plex economy, with more actors contributing to (cheaper) drugs, using a drug group number the direct costs of health care, universal health available online, bypassing the telephone insurance, pharmaceutical benefits, an evolving approval process. Some drugs, such as isotretin- regulatory framework, the National Medicines oin (Roaccutane), are prescribed only by special- Policy, and a complex interplay of intrinsic and ists. extrinsic factors that influence the doctor–phar- When patents expire, medicines prices fall as macist relationship. Some ways forward will also cheaper generic brands become available, making be discussed. more cost-effective care possible.6 However, there are many vexed issues for policymakers, regula- tors and professionals in this area, including the The Australian National Medicines sometimes significant delay between patent Policy expiry and the availability of a generic,7 market The Australian National Medicines Policy (NMP) distortions through authorised or “pseudo- incorporates four tenets: (1) availability, quality, generic” brands,8 and the difficulties (addressed safety and efficacy; (2) timely access to affordable through recent PBS changes) of generating cost medicines; (3) quality use of medicines (QUM); benefits for consumers and the government from and (4) a responsible and viable medicines indus- the availability of cheap generics. Strategies to try. The NMP encompasses a mix of educational, foster the use of generic medicines include differ- managerial and regulatory strategies to promote ential subsidies to promote them over proprietary QUM, emphasising links among government, drugs9 and allowing pharmacists to substitute industry, consumers, prescribers and dispensers generic drugs for proprietary brands, legalised in of medicines. In its early stages, the development Australia in 1994.10 However, while there are and implementation of the NMP was coordinated now government incentives for Australian phar- by the now dormant Australian Pharmaceutical macists to dispense generic brands,11 there are no Advisory Council (APAC), which included repre- similar incentives for doctors to prescribe them.12 sentation from all major professional and con- The “down-scheduling” of many previously sumer groups. prescription-only medications in Australia means pharmacists are “prescribing” an increasing range Equity and access to affordable medicines of medications (eg, non-steroidal anti-inflamma- Medicare Australia subsidises medicines and tory drugs, histamine H2-receptor antagonists, health services through the Pharmaceutical Bene- emergency contraception). The “pharmacist only”

Australian Health Review May 2009 Vol 33 No 2 269 Innovation and Professional Realignments scheduled medicines, also available in many nising that doctors, pharmacists, nurses and con- other countries, represent another strategy to sumers all play roles in ensuring QUM. This gives improve access. rise to many challenges as teams must work across service boundaries and differing organisa- Safety and quality in the use of medicines tional, financial, professional and disciplinary For a drug to be legally available to individuals in requirements and priorities. In the management Australia, it must be approved by the Therapeutic of chronic disease, the experience is as yet subop- Goods Administration (TGA). Listing on the PBS timal with the recognition that multidisciplinary requires a recommendation by the Pharmaceuti- teams need to work more effectively.18 Collabora- cal Benefits Advisory Committee (PBAC) and final tion between general practitioners and other approval by the Commonwealth Minister for health services often falls short of expectations.19 Health or, if high costs can be anticipated, by the In this context, there are significant tensions full Cabinet. In addition, the National Strategy for and unintended effects associated with the multi- Quality Use of Medicines13 has a number of QUM disciplinary approach to QUM and especially strategies in place. The National Prescribing Serv- with the relationship between prescribers and ice (NPS) was formed to provide independent dispensers. This paper examines the practical advice to government and independent informa- philosophy of the apothecary, its evolution into tion to health professionals and consumers. In the separate roles of the pharmacist and the January 2008, the QUM map (www.qum- general practitioner, and the implications of this map.net.au) listed 1429 projects to promote divide. Historical antecedents, an evolving regula- QUM in Australia. These range across disciplines; tory framework, health insurance and pharma- hospitals and general practice; regulatory, mana- ceutical benefits, and a complex interplay of gerial and educational strategies; and all attributes intrinsic and extrinsic factors will be explored in of QUM, which include efficacy, effectiveness, relation to the doctor–pharmacist relationship. equity, safety, appropriateness and costs.14 Safety is an increasing priority. An estimated 16% of hospitalised patients suffer an adverse Methods event, with 50% of these events being preventa- The literature was surveyed from the perspective 15 ble. Admissions in Western Australian public of multidisciplinary and interprofessional care, hospitals due to adverse drug events (ADEs) in general practice, pharmacy practice, primary people aged 60 years or over showed a five-fold health care, and quality use of medicines. A increase in the age-standardised rate of ADE- narrative review was conducted and the findings related hospital stays between 1981 and 2002, reported below. with more than a doubling in the rate between 1991 and 2002.16 The largest increases occurred in those aged over 80 years — a worrying finding Findings given the ageing Australian population. About 10.4% of the 17.5 million people who make 95 Historical antecedents million visits to their general practitioner annu- The general practitioner and the pharmacist share ally will experience an ADE; about one million a common ancestor — the apothecary. The ante- being moderate or severe and 138 000 requiring cedents of apothecaries can be found in ancient hospitalisation.17 Egypt, Mesopotamia and Sumeria.20 The first recorded apothecary shops, which prepared “. . . a A multidisciplinary approach to safety and wide range of medicines including classical, Per- quality in the use of medicines sian and Indian drugs and chemicals”, appeared The National Strategy for Quality Use of c. 850 AD.21 Persian scholars introduced many Medicines13 is multidisciplinary in nature, recog- medical and medicinal concepts into Europe. The

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Edict of Palermo, issued in 1231, stated that the apothecaries from giving advice and treatment” medicine and pharmacy were separate profes- to the poor and middle classes.23 The House of sions requiring distinct skills, for example, com- Lords’ decision took into consideration adherence pounding medicines versus diagnosis. It to custom and the “public interest”. The argument stipulated government control over many aspects that the poor should also have access to medical of market entry, contracting and payment: physi- services thus enabled the apothecaries of England cians and apothecaries were not to enter into and Wales to integrate prescribing and dispensing. business relationships, and the number of apoth- The Apothecaries Act (1815) recognised the role of ecaries, their locations and prices were subject to the Society of Apothecaries to license apothecaries government oversight. The financial motivation in the field of medicine — forerunners of the appeared to be the association of medicines with general practitioner. the commercially vital spice trade. It also helped The Edict of Palermo, which separated dispens- that apothecaries had a relatively high social rank ing from prescribing, was a pragmatic strategy by that allowed their profession to stake an inde- a medieval European state to regulate the manu- pendent claim on the role of dispensing. facture and sale of drugs. By the 18th century, this This government-decreed separation spread was common practice in Europe. In the UK, across medieval continental Europe, regulated by however, this separation was only consolidated central and local government authorities as well through the welfare state and third-party pay- as professional guilds.20 Apothecaries were not ments arising from the 1911 National Insurance distinguished from dealers in eastern and Bill and subsequent insurance scheme.24 Pharma- spices (“spicers”), and overlapping functions con- cists were given the legal authority over dispens- tinued into the 18th century.22 Apothecaries were ing in England. Doctors could still dispense for in guilds alongside surgeons and barbers or had uninsured dependents, in rural areas with no their own guilds. Disputes over professional pharmacy and in after-hours/emergency situa- boundaries with were common. Five tions. Although the rural exception continues to hundred years after the Edict of Palermo, the today, the separation of prescribing and dispens- 1777 Royal Declaration in France established ing spread to cover almost all the population in professional pharmacy in France and prohibited conjunction with universal coverage under the competing organisations, such as religious hospi- UK National Health Service after World War II. tals and societies, from selling drugs. Similarly, in Australia universal health insurance In 1617, King James I of England signed a and pharmaceutical benefits have consolidated charter establishing the Society of Apothecaries as the separation of prescribing and dispensing. a corporate body,22 with the caveat that the English However, recent initiatives to promote an apothecary “understood that he was not permitted expanded role for pharmacists — pharmacist to charge for his consultation, and was quite prescribing and involvement in health promotion prepared to rely on the sale of drugs and medicines and prevention — appear to reflect a growing for his profit”.23 While the Apothecaries’ Charter recognition of the value (and cost-effectiveness) did not specifically prevent apothecaries from of the apothecary model. Does this mark a return examining and treating patients, “it was accepted” of the apothecary or apothecarial practice by the that apothecaries could only charge for drugs. This pharmacist and doctor? institution shaped the legal rules defining profes- sional boundaries. The Society of Apothecaries Back to the apothecary? won (on appeal to the House of Lords) a case brought against a member for providing medical Pharmacist prescribing advice to a patient because “their Lordships In England, pharmacist supplementary prescrib- accepted the argument that it was contrary to ing and independent prescribing were introduced custom and against the public interest to prevent in 2003 and 2006, respectively, to improve access

Australian Health Review May 2009 Vol 33 No 2 271 Innovation and Professional Realignments to medicines and better utilise the skills of health Expanded roles for pharmacists care professionals. To be eligible, pharmacists The pharmacy profession is currently exploring must have at least 2 years’ post-registration clini- expanded roles in primary care. These include cal experience in the UK.25 Pharmacist supple- prevention and aspects of chronic disease mentary prescribing was allowed for a specific management36 with medication reviews in indi- non-acute medical condition or health need in viduals’ homes or residential aged care facili- accordance with a clinical management plan ties,37,38 and the development of formularies and agreed with a medical/dental practitioner and reviewing repeat prescriptions.39 These are patient. Supplementary prescribing was extended changes which give rise to new models of inter- in 2005 to include podiatrists, physiotherapists, professional care in the hospital and commu- radiographers, and optometrists. Supplementary nity.39 Pharmacists can improve prescribing prescribers must work within their professional practices, reduce health-care utilisation and med- competence and must consult and where neces- ication costs, and contribute to clinical improve- sary pass back prescribing responsibility to the ments in many chronic medical conditions, such medical/dental practitioner. The independent as cardiovascular disease, diabetes, and psychiat- pharmacist–prescriber assumes responsibility for ric illness.41-43 Studies show that pharmacist the assessment and consequent clinical manage- involvement in therapeutic monitoring improved ment, including prescribing, for both undiag- adherence to medicines and costs in asthma44 and nosed and diagnosed conditions. While outcomes of lipid-lowering drug therapy.45,46 increasing, independent pharmacist prescribing Pharmacists accompanying physicians to visit in 2006 represented only 0.004% of primary care patients with complex medical conditions prescribing.26-28 Cardiovascular medicines were reduced costs and simplified medicines regimes the most frequently prescribed, followed by cen- without reducing quality of care.47 Pharmacists tral nervous system, respiratory, endocrine and employed in primary care practices controlled gastrointestinal medicines. prescribing costs sufficiently to offset their The implementation of the UK supplementary employment costs.48 and independent prescribing programs included Experience to date indicates that while doctors training and a -supervised practicum to were content for pharmacists to provide informa- ensure public safety and probity, and a capacity to tion regarding medicines or do simple health distinguish between professional and commercial checks, they were less happy for them to be responsibilities.29 The English Department of involved in prescribing decisions49-51 or to write Health attempts to address potential conflicts of sickness certificates for mild illnesses.52-53 interest surrounding prescribing and dispensing The available evidence for an expanded role of responsibilities by requiring that, where a phar- pharmacists in prescribing and medication man- macist both prescribes and dispenses a medicine, agement draws mainly on descriptive and small- a “second check” must be carried out by a scale studies.54 More high-quality and larger suitably competent person.25 scale studies are needed for a comprehensive In the US and Canada, pharmacists are able to assessment of the effectiveness of an extended legally prescribe a range of medicines.29,30 In the role of pharmacists as independent health pro- USA, protocol-based prescribing by pharmacists fessionals or as participants in the multidiscipli- by 2001 had been successfully legislated in at nary team.55-57 least 25 states.29 The limited international experi- ences to date (UK, US, and Canada) suggest that Tension areas between doctors and pharmacists pharmacists are capable of prescribing a range of The changing role of pharmacists, and the possi- drug therapies safely and effectively, including bility that their responsibilities could be extended oral contraceptives, analgesics, antihypertensives further, is associated with an underlying tension and warfarin.29-35 between doctors and pharmacists. The issues

272 Australian Health Review May 2009 Vol 33 No 2 Innovation and Professional Realignments revolve around professional authority and prac- consumer spending on complementary and over- tice, remuneration and patient care. the-counter medicines.60 There is a widespread perception that doctors Rising medicines costs for consumers as a and pharmacists prescribe and dispense to consequence of higher PBS copayments (Sweeny increase income or other benefits, and that their in this issue, page 215) risk increasing the poten- behaviour is influenced by links with drug manu- tial for unsupervised patient self-treatment, lead- facturers. While separation of dispensing removes ing to inappropriate use of medicines. A direct financial incentives from doctors’ prescrib- particular risk is not recognising serious illnesses, ing decisions, financial incentives may influence with serious or even fatal consequences. It is pharmacists’ dispensing: for example, whether to important to enhance self-care skills, encourage propose generic substitution and their choice of use of safer alternatives, discourage indiscrimi- generic brand.12 However, patients are not neces- nate use of potent medicines like antibiotics and sarily able or willing to pay out of pocket for encourage the seeking of assistance with more medicines, and professional norms and reputa- serious diseases. An interprofessional question is tional mechanisms provide constraints on inap- whether the pharmacist or non-medical pre- propriate behaviour.58 There are no studies scriber is sufficiently prepared or motivated to directly comparing the cost-effectiveness of doc- promote QUM by the self-medicator. tor and pharmacist dispensing, but a review of the strategies by East Asian countries to achieve Issues with expanded roles for pharmacists separation concluded that neither physician nor Major reservations about prescribing by pharma- pharmacist dispensing was intrinsically more cists and other health professionals include the cost-effective than the other.3 lack of access to complete medical records, and In Australia, the mix of multidisciplinary strat- accountability and compromised patient safety egies to promote QUM within a cost-effectiveness from not separating prescribing from dispens- model highlights these tension areas. This is ing.25,61 There are frequent misunderstandings or particularly evident in relation to the promotion discrepancies between the patient’s actual intake of an increasing and broader role for pharmacists of drugs and the medication profile recorded by in prescribing, and in the prevention and man- the patient’s doctor.62-64 Non-medical prescribing agement of chronic disease in a growing elderly can cause medication misadventure, especially if population. The complex network of relation- communication among care providers is poor. ships within the QUM strategy, with actors pursu- Information exchanged is often lacking in rele- ing different agendas, will influence, positively vant content and timeliness.19 Integrated care and and negatively, the professional and personal interprofessional teams are desirable, but teams relationships in predictable as well as unantici- need to work together effectively18 and agree on pated ways. responsibility for communication and continuity of care.65 Patient self-treatment Drug-related problems in aged care, where The self-management activities of the patient and pharmacist prescribing is being advocated, are consumer,59 especially self-medication, are a sig- multifactorial and complex. Issues include lack of nificant factor. Self-treatment, defined as diagnos- prescribing knowledge, presence of multiple ing a health problem, choosing medication or comorbidities, altered physiological states and, treatment and administering this without professional most frequently, simple misunderstandings in assistance, is of course common. Patients will seek communication, leading patients to “fall through medical expertise to obtain a medicine or, if the cracks” in an increasingly complicated health knowledge of the medicine and its proper use is care system.66,67 About one-third of elderly available directly, self-medicate. Self-medication patients receive prescribed drugs from two or is prevalent in Australia, where there is significant more doctors.68 It is therefore not surprising that

Australian Health Review May 2009 Vol 33 No 2 273 Innovation and Professional Realignments the principal cause of preventable drug-related Traditionally, the general practitioner has been the admissions to hospital is communication failures gatekeeper to the health care system, with control between patients and health care professionals, as over access to most services, including drug well as among health care professionals.69 This therapy for chronic diseases. A weakening of this fragmented approach to multiple medication and role would in some circumstances eliminate the disease management places vulnerable elderly need for a general practitioner visit, at least after patients at increased risk of adverse drug events.70 the initial diagnosis and receipt of the first pre- Alterations in physiology, use of several pharma- scription. Because a visit to a general practitioner cies, multiple prescribers, and other factors place and the ensuing receipt of a prescription poten- the elderly population at risk of developing tially reinforces the patient’s understanding of the adverse drug reactions and clinically significant need for therapy, shifting the prescribing of medi- drug–drug interactions.71 cations for chronic diseases to other health care Having multiple prescribers (eg, specialist, gen- professionals may negatively affect the patient’s eral practitioner, nurse and pharmacist) can cause perception of the need for and effectiveness of confusion and lead to duplication of therapy, 72,73 medication.79 This has significant implications for and other forms of medication misadventure. the safety and quality of care. Excellent communication is required to ensure that all prescribers are aware of the total thera- peutic management of the patient. A central Some ways forward coordinating and oversight role by the general The evidence on the cost-effectiveness and QUM practitioner appears to be important.73 A large implications of expanding pharmacist roles in Canadian study demonstrated that the greater the prescribing, chronic disease management and number of clinicians prescribing medications for prevention is still sparse. However, the potential an elderly patient, the greater the risk that the in terms of safety, quality and interprofessional patient will receive a potentially inappropriate workforce capacity is great despite the areas of drug combination.74 A systematic literature tension described. It is therefore important to review concluded that the number of prescribers, build the evidence base for this interprofessional and the number of dispensing , is clinical area. important in determining the prevalence of clini- cally relevant drug–drug interactions.75 An Aus- Safety and quality: data and monitoring tralian study also found that having multiple The successful implementation and governance prescribers increased patients’ key medication- of the NMP require data collection and monitor- related risk factors and was associated with poor ing systems, linking drug utilisation, health serv- health outcomes.76 ices and clinical information, to enable cost- Non-medical prescribing can lead to too many effective and appropriate prescribing of medi- specialist health professionals, each prescribing cines, including those used off-label and outside medicines, without the oversight of a general PBS-approved indications (“leakage”). It is impor- practitioner.77 General practitioners typically have tant to have consensus definitions and nationally a comprehensive and holistic approach to health agreed benchmarks for QUM, interprofessional and illness, which differentiates them from spe- practice and associated health outcomes. cialists.78 When technical or specialised disease- The main sources of information about QUM in orientated care bypasses the GP, it is very likely Australia are (1) Australian Statistics on Medi- that important elements of care may be cines (ASM);80 and (2) BEACH (Bettering the neglected.73 Evaluation And Care of Health) reports on gen- Concerns have also been raised about the eral practice activity in Australia.81 The ASM public’s perceptions of a broadening role of phar- dataset is derived from PBS utilisation (dispens- macists and other health care professionals.79 ing) data and does not include a large proportion

274 Australian Health Review May 2009 Vol 33 No 2 Innovation and Professional Realignments of public hospital drug use, drugs costing less tice will not occur.87 Unless academic settings are than the patient copayment, over-the-counter developed to provide training for primary health purchases (except for S3 recordable medicines) or care professionals to work in teams, reform initia- the supply of highly specialised drugs to outpa- tives are unlikely to generate anticipated bene- tients through public hospitals under Section 100 fits.86 Collocation, as envisaged in the GP Super of the National Health Act 1953 (Cwlth). The Clinics program currently being introduced by Fourth Community Pharmacy Agreement the Australian Government, is a promising model between the Australian Government and Phar- to evaluate. macy Guild of Australia will provide greater We coined the term “apothecarial” to describe access to complete dispensing data (including less the approach of integrating the complementary than copayment and safety-net items) from Aus- roles and responsibilities for the prescriber and tralian community pharmacies. Finally, informa- dispenser in the patient–clinician therapeutic tion from general practice electronic prescribing relationship. An example of the apothecarial packages, which include linked diagnosis data, approach is the Integrating Family Medicine and will enable more comprehensive assessment of Pharmacy to Advance Primary Care Therapeutics the appropriate use of medicines.82 (IMPACT) project, which was designed to provide a demonstration of the feasibility of integrating An integrated interprofessional and the pharmacist into primary care office practice in patient-centred approach Ontario, Canada. The IMPACT multifaceted prac- If pharmacists are to assume prescribing rights, tice model includes the embedded pharmacist there needs to be close collaboration and commu- performing medication reviews for individual nication between doctors and pharmacists.40,41,83- patients, providing pharmaceutical information 85 How do we enhance this interprofessional to health care providers, conducting system-level relationship, communication and practice to activities to promote QUM and communicating achieve appropriate use of medicines? There is with other providers and pharmacists, and activi- still confusion on what constitutes optimal inter- ties to integrate the pharmacist into the practice. professional health practice, which is not surpris- The IMPACT program has identified significant ing considering the lack of formal teaching of drug-related problems, for example not receiving interprofessional collaboration.86 Even in the pri- a medicine, not receiving it appropriately or mary care and family practice setting, where most receiving too low a dose, in the participating of the early efforts have concentrated, the practices. System-level changes include drug resources are marginal at best. Interprofessional administration plans and chronic disease man- tension is still prevalent. agement protocols, alerts and reminders. All the Mutual trust and respect are essential elements relevant Family Health Trusts have adopted the of interprofessional relationships.87 If these ele- IMPACT model for the next round of funding.40 ments are truly present, then members of the health care team can together determine, on the basis of their shared understanding of each oth- Conclusion ers’ roles and expertise, who will lead the team in The historical separation of prescribing and dis- a given patient care context. Transparency of pensing in Europe is explained by professional, decisions, including financial ones, must be a key regulatory and commercial factors which are still shared principle. Collaborative practice requires relevant today. Separation does not guarantee cost negotiation and a non-competitive, non-hierar- efficiencies or effectiveness or appropriate use of chical approach to patient and client care. Until medicines. The incentives, challenges and con- health care workers (including doctors and phar- flicts of interest may just take different forms, and macists) agree on what collaborative practice the potential for conflict of interest based on entails, true interprofessional collaborative prac- financial incentives remains.

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